Relevance of Oral and Maxillofacial Surgery dental records for trauma hospital

WILLIAN MARTINS AZEREDO1 | GIULIANO TEIXEIRA PACHER1 | ANTONIO EUGÊNIO MAGNABOSCO-NETO1

Objective: To propose a model of dental record for the area of Oral and Maxillofacial Surgery and Traumatology for use in hospital trauma services. Method: This is an experience report on the preparation of dental records, conducted from June to December 2019, during a Uniprofessional Residence of Oral and Maxillofacial Surgery and Traumatology in a public hospital in southern Brazil. Results: The clinical record was made based on the literature and divided into four sessions, which were organized between personal data, health history, trauma assessment, as well as intraoperative and postoperative information Conclusion: The preparation and correct completion of the dental record in the area of Oral and Maxillofacial Surgery and Traumatology are essential for the diagnosis, planning and correct treatment of each case. In addition, they favor epidemiological records and facilitate communication between multi-professional team of the hospital trauma service.

Keywords: Patient care team. Dental staff, hospital. Trauma centers. Internship and residency.

1 Hospital Municipal São José, Serviço de Cirurgia e Traumatologia Buco-maxilo-facial (Joinville/SC, Brazil).

» The authors report no commercial, proprietary or financial interest in the products or companies described in this article. How to cite: Azeredo WM, Pacher GT, Magnabosco-Neto AE. Relevance of Oral and Maxillofacial Surgery dental records for trauma hospital. J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):32-7. DOI: https://doi.org/10.14436/2358-2782.7.1.032-037.oar

Submitted: January 19, 2020 - Revised and accepted: March 24, 2020

Contact address: Willian Martins Azeredo Rua Visconde de Mauá, 2268, bloco B, apartamento 402 Santo Antônio, Joinville/Santa Catarina CEP: 89.204-500 E-mail: willianazeredo@gmail.com

The dental record is considered a document of the patient that should be prepared and stored by the dental professional. Also, the dental professional should assure the access to medical records whenever necessary, since it is a legal document.1 Dental documentation is considered adequate when it includes all data and information provided by the patient, as well as information found on the physical examination and complementary exams.2 Records as certificates, declarations of attendance to the consultation and prescriptions should also be attached to the dental record, besides the clinical form.2,3

Oral and Maxillofacial Surgery and Traumatology (OMFST) is a surgical specialty in Dentistry that aims to offer treatments and care to patients with dentofacial deformities and trauma. In OMFST, the dental clinical record is essential, since data included will assist in the diagnosis and planning of each case. Thus, the use of a specific clinical form in the area, which includes personal, historical, extraoral and intraoral examinations, as well as relevant information on intraoperative and postoperative periods, is essential for planning, seeking to offer the best treatment and prognosis to individual in need of care.4 Also, the use of medical records facilitates the generation of knowledge among health team professionals, who need to identify the patient’s condition to perform interventions.5

To favor the standardization of information for epidemiological studies and facilitate the communication of the multidisciplinary hospital team, the present research aimed to propose a model of clinical dental records for the area of Oral and Maxillofacial Surgery and Traumatology to be used in hospital trauma services.

This research is an experience report on the development of a clinical dental record, performed during Uniprofessional Residency in Oral and Maxillofacial Surgery and Traumatology in a public hospital in southern Brazil. The form was created due to the need to standardize data and information collected during anamnesis and physical examination of patients assisted at the service.

Preparation of the dental clinic record occurred from June to December 2019, based on the literature related to mandatory documents that must be included in the medical records of patients treated at OMFST services.

The clinical record was developed in four sessions, aiming at capturing different information from patients treated at the trauma service in a public hospital located in southern Brazil by a OMFST team. Due to regional standards, it was decided to make questions directed to the profile of individuals.

The first section includes personal data of the patient, presence or absence of comorbidities, allergies and use of continuous medications. It aims to assess the general health status of the patient prior to trauma and to include legal information on the individuals, as well as to report the number of services in the hospital unit (Fig 1).

The second section concerns the initial assessment performed during the care of traumatized patient in an emergency care unit, including information as the etiology of trauma, Glasgow scale, presence of soft tissue injuries, paresthesia on the face and presence or absence of visual, respiratory and occlusal complaints (Fig 2).

In the third section of the clinical record there are sites for notes on the facial trauma presented. To improve the division and study of facial fractures, it was decided to divide the facial skeleton into fractures of the mandible, maxilla, frontal bone, orbital zygomatic complex and nasal bones, as well as a chart to fill in the preoperative laboratory exams (Fig 3).

The fourth and last section of the clinical record addresses questions about the transoperative period, with topics related to type of intubation, procedure performed, fixation of fractures presented, intraoperative complications and information on the immediate postoperative period. At the end of the clinical record, there are sites for completing and signing by the professional responsible for data collection and physical examination. There are also spaces for signature by the patient or legal caretaker (which attest the information as true) and for the date of clinical examination (Fig 4).

Figure 1: First section: legal and personal information of the patient.

Figure 2: Second section: information regarding the etiology of facial trauma.

Figure 3: Third section: information regarding the facial trauma in relation to the affected bone structure.

Figure 4: Fourth section: trans- and postoperative information.

The Federal Dental Council, in its code of ethics, Chapter VII, Article 17, exposes the obligation of dental professionals to prepare and perform proper maintenance of patient records, either digitally or in physical forms.6 Most dental professionals prefer the use of physical records, with printed questionnaires to collect data on the anamnesis and physical examination7. For a correct filling of the dental record, it is fundamental to achieve the patient’s signature after the information is collected.2

The current literature is scarce regarding the accomplishment and adequacy of dental records in the field of OMFST in the hospital environment. Most studies refer to the conduct of dental professionals in relation to medical records in non-hospital environments.1,3

One of the factors that cause damage in the collection and storage of data from patients’ clinical records is their inadequate filling.8 In a study by Angeletti and Abramowics9 evaluating dental records, it was observed that 93.2% of records were incomplete. One of the possible causes reported by Costa10 for this fact is the lack of specific predetermined fields to be filled, due to poor design of the clinical records. Due to this reason, during development making of this clinical record, it was decided to keep separate fields for each information to be inserted.

Several failures, such as lack of general health information and facial trauma, are worsening when it is intended to perform a specific and detailed treatment plan for each patient, besides presenting insufficient data for epidemiological analyses.11 For this reason, this clinical record was proposed with four sections, to avoid losing essential information for diagnosis and treatment planning in OMFST.

The first section of the questionnaire was composed of questions of legal and personal nature of the patient to be evaluated by the OMFST team. Approximately 55.5% of professionals qualified in health care believe that only the personal information of patients has mandatory filling.2 The approach should be performed in a systematic manner, which requires a specific approach during interview to collect information as the chief complaint, previous pathological history, allergies and use of medications.12 To present the proposal for a standardized clinical record, it was decided to follow a logical order to collect the patient information.

Due to the importance of initial evaluation by the OMFST team of patients with facial trauma,13 it was decided to define the information to be asked to the patient in the second section. The etiology of facial trauma is varied and is related to local, social and cultural aspects of individuals.14 For this reason, questions about the etiologies of injuries were included in this section.

The facial bones, when compared to each other, have different characteristics. Fractures can be classified in different manners, such as: fractures of the mandible, zygomatic complex, maxillary bones, nasal bones15 and of the external plate of the frontal bone.16 They can also be classified as zygomatic, mandible, orbit, nasal, maxilla, frontal and naso-orbito-ethmoidal fractures.17 In the third section of the clinical record, aiming at facilitating the treatment and study of such lesions, it was decided to choose the first classification system, since the bone structures that make up the orbit region belong to previously mentioned structures, as well as the fact that nasal fractures can present in isolation, not associated with other structures.

According to Carvalho et al.18, laboratory tests should be requested before surgical interventions for a better evaluation and treatment decision in each case, which demonstrates the importance of the third session of the designed dental clinical record. The same authors state that part of professionals request laboratory tests without knowledge of their indications and consequently of their interpretation, which affects the planning and surgical indication.18

The clinical record, when properly filled out, may encourage professionals to obtain such knowledge.19 During preparation of the clinical record of this study, it was decided to insert a table in which the professional can fill in the results of tests requested during the entire hospitalization period of the patient. One of the causes found by Silva and Tavares Neto20 for inadequate filling of the medical record was the lack of adequate space for recording information.

On the fourth section of the clinical record, it was necessary to insert information regarding the transoperative period. The accomplishment of surgical procedures by the OMFST team sometimes requires interventions in different facial bones at the same surgical time and thus there are specific needs regarding the patient intubation.21 The procedure can be performed with orotracheal, nasotracheal or submental intubation or even tracheostomy.22

The treatment for facial fractures varies according to the injuries presented by the individuals and can be classified as conservative (without surgical intervention), closed reductions and extraoral accesses for rigid fixation with Miloro plates and screws.12 It is also necessary to monitor the patient in the postoperative period and make notes in the clinical record.4,12 For that reason, topics were also added to that section.

The development and correct filling of the dental clinic file in the area of Oral and Maxillofacial Surgery and Traumatology are fundamental for the diagnosis, planning and correct treatment of each case. Also, they favor the epidemiological records and facilitate communication between the hospital trauma service team.

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